Tatalaksana Kejang Intraoperatif pada Operasi Glioma dengan Tehnik Awake Craniotomy

Abstract

Tehnik Awake Craniotomy (AC) untuk reseksi tumor glioma di area eloquent, menjadi pilihan untuk menghindari gangguan neurologis dan kognitif pascabedah. Perempuan, 34 tahun, diagnosa tumor intra-axial (high grade glioma), dengan keluhan kejang fokal pada tangan kiri sejak 4 bulan sebelumnya. Pemeriksaan MRI kepala dengan kontras ditemukan massa supratentorial intra-axial mengesankan suatu primary malignant brain tumor (high grade glioma). Dilakukan operasi AC dengan Monitored Consciuos Sedation (MCS), menggunakan dexmedetomidine dan scalps block. Selama operasi pasien mengalami 3 kali kejang, dari kejang fokal sampai kejang umum. Lama operasi 4 jam, reseksi tumor lebih dari 60%, operasi selesai karena pasien mengalami gangguan fungsi motorik pada ekstremitas atas dan bawah kiri. Pascabedah di rawat di ICU selama 2 hari, mengalami satu kali kejang pascabedah, dengan hemiparese sinistra grade 3. Kejang merupakan salah satu komplikasi yang paling sering dilaporkan pada prosedur AC. Kejang intraoperatif bisa menggagalkan AC, diganti ke anestesi umum dengan intubasi atau pemasangan laryngeal mask airway (LMA), dan kejang saat AC dikaitkan dengan meningkatnya morbiditas dan lama perawatan di rumah sakit Pemilihan pasien yang tepat, dukungan psikologis perioperatif, tim anestesi dan bedah yang berpengalaman memegang peranan penting dalam keberhasilan operasi dengan prosedur AC.

Management of Intraoperative Seizures during Awake Craniotomy in Glioma Tumors

Abstract

The Awake Craniotomy (AC) technique for resection of glioma tumors in the eloquent area is performed, while preserving neurological and cognitive functioning. Female, 34 years old, diagnosed with an intra-axial tumor (high-grade glioma), with complaints of focal seizures in the left hand since 4 months before. Head MRI examination with contrast found a supratentorial intra-axial mass suggesting a primary malignant brain tumor (high-grade glioma). AC surgery was performed with monitored conscious sedation (MCS), using dexmedetomidine and scalp blocks. During the operation, the patient had three seizures, ranging from focal seizures to generalized seizures. Operation time was 4 hours, tumor resection was more than 60%, and the operation was completed because the patient had impaired motor function in the left upper and lower extremities. Postoperatively, he was treated in the ICU for 2 days and experienced one postoperative seizure with grade 3 left hemiparesis. Seizure is one of the most commonly reported complications associated with awake craniotomy. Intraoperative seizure resulted in AC failures, requiring intubation or laryngeal mask airway change to to general anesthesia, and seizures during AC were associated with increased neurological short-term morbidity and a longer length of hospital stay. Selection of the right patient, perioperative psychological support, an experienced anesthetic and surgical team play an important role in the success of surgery with AC procedures.